Did Sir Louis earn it?

Did Sir Louis earn it?

Professor Louis Appleby has received a Knighthood in the 2023 New Year’s Honours listed for his ‘services to medicine and mental health’. No doubt he is being congratulated widely. However, do his services to mental health really bear close examination?

He leads the National Suicide Prevention Strategy for England. Such a strategy is vital to combat the 6,000 suicides that happen in England each year. Apart from the waste of life and the terrible pain caused to families, each suicide costs the UK £1.7 million (total annual cost more than £10 billion). It’s essential to stop this carnage. Above all else, the strategy must make clear who are at greatest risk and ensure those who interact with them – medics, friends, family – are aware.

Professor Appleby has failed to include important information about a high risk group – a group numbering thousands, probably millions of people [1]. The strategy does not mention head injury survivors!

The evidence is unarguable. There are two large Danish population studies, one covering more than 145,000 head injured patients, and the other around 34,000. These studies both divide the head injuries into three categories: concussion, skull fracture and severe brain injury, with severe brain injury carrying the greatest risk. Their findings are that concussion gives a risk between twice and three times the national average, skull fracture twice and severe head injury between twice and four times. [2,3]

Why does the Strategy not protect these people by including them? Why highlight agricultural workers, whose risk is twice the national average, and not a group whose risk is substantially more?

The clue may lie in the reason why head injury survivors are so likely to kill themselves. As this website demonstrates elsewhere, around a quarter of them have compromised hormones.

Disturbances in each of five of the pituitary hormones are associated with depression, and with three of these affected hormones there is a link with suicide. [4,5,6,7,8,9,10,11,12] Taken separately these risks are significant, but combined, as they usually are in post-traumatic hypopituitarism, they may be overwhelming.

Yet compelling though the evidence is, there is widespread reluctance to publicize the problem. Professor Appleby, when challenged, claimed that the head injury risk was ‘mediated’ by other factors such as poverty, implying that there was no direct connection. Yet the close correlation between the nature of the injury (concussion, skull fracture and severe) and the degree of risk argues that the connection is very direct indeed.

In fobbing off protests, the professor has aligned himself with the National Institution of Clinical Excellence, who refused for fourteen years to mention pituitary dysfunction in their head injury guidance, and with charities such as the British Heart Foundation, who despite incontrovertible evidence dating back 19 years refused last year to state on their website that growth hormone deficiency is one of the causes of heart disease. (Both these organisations, I’m happy to say, have recently had second thoughts.) It could be conjectured that the expense of lifelong hormone therapy, particularly growth hormone injections, encourages the government to muffle the extent of the problem.

Whatever the motives of Sir Louis and these other organisations, the effect has been a profound ignorance in the medical community about hypopituitarism and its consequences. Instead, endocrine patients are often told that they have ME or Chronic Fatigue Syndrome, or Fibromyalgia or Metabolic Syndrome, and there is a prevailing popular belief that these patients somehow cause their own illness by incorrect mental attitudes. It’s no wonder that the suicide rate for ME and Chronic Fatigue Syndrome has been estimated at six times the national average. [12]

Professor Appleby hasn’t put that in the Suicide Strategy either!

[1] 1.4 million people go to A&E each year with head injury, according to NICE. If a quarter of these have undiagnosed pituitary damage this adds up to well over two million per decade.

[2] Teasdale TW, Engberg AW, Suicide after traumatic brain injury: a population study, J Neurol Neurosurg, Psychiatry 2001) http://jnnp.bmj.com/content/71/4/436.full

[3] Madsen, Trine et al, Association Between Traumatic Brain Injury and Risk of Suicide, JAMA 2018 https://jamanetwork.com/journals/jama/article-abstract/2697009

[4] Kelly, D F et al, Neurobehavioral and quality of life changes associated with growth hormone insufficiency after complicated mild, moderate or severe traumatic brain injury, 2006, J of Neurotrauma 23(6): 928-42. http://online.liebertpub.com/doi/abs/10.1089/neu.2006.23.928?journalCode=neu

[5] Mahajan et al, Atypical depression in growth hormone deficient adults and the beneficial effects of growth hormone treatment on depression and quality of life Eur J Endocrinol 151(3) 325-32, 2004

[6] Hypothalamic Pituitary Adrenal Axis and Prolactin Abnormalities in Suicidal Behavior, 2013 https://pubmed.ncbi.nlm.nih.gov/24040800/

[7] Makhlouf A et al, Hypogonadism is associated with overt depression symptoms in men with erectile dysfunction, 2008, International J. of Impotence Research 20:2:157-161 http://www.mendeley.com/research/hypogonadism-associated-overt-depression-symptoms-men-erectile-dysfunction/

[8] Mazer NA, Testosterone deficiency in women: etiologies, diagnosis and emerging treatments, 2002, Int J Fertil Women’s Med Mar-Apr 47(2) 77-86 http://www.ncbi.nlm.nih.gov/pubmed/11991434

[9] The Pituitary Foundation GP Fact File 2011, section on Hypogonadism: “Symptoms include tiredness, reduced libido and sexual functioning, reduced body and facial hair and muscle mass, infertility and a lack of general well-being including depression.”

[10] Raised prolactin levels
Black McL, Loeffler JS, Cancer of the nervous system, 2005, John Wiley and Sons: “Reports in the literature first started appearing about 25 years ago, suggesting a relationship between prolactin levels and depression (86). Several other reports have documented the association between elevated prolactin levels and depression (87, 88)” http://books.google.co.uk/books?id=CTGXvRvKO2kC&pg=PA261&dq=raised+prolactin+levels+depression+cancer+of+the+nervous+system&hl=en&sa=X&ei=CGP5ULCCCOW00QX4xoDICA&ved=0CDEQ6AEwAA#v=onepage&q=raised%20prolactin%20levels%20depression%20cancer%20of%20the%20nervous%20system&f=false

[11] Association of Thyroid Function with Suicidal Behavior: A Systematic Review and Meta-Analysis, Toloza F et al., Medicina (Kaunas), 2021, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303342/

[12] Mortality of people with chronic fatigue syndrome, Roberts E et al, The Lancet, 2016, discussed here in the Kings College London News Centre Archive https://www.kcl.ac.uk/archive/news/ioppn/records/2016/february/suicide-six-times-more-likely-in-cfs-patients-compared-to-general-population (a small study but significant)